Pet Urgent Care

Patient Intake Form

Visit Information

Date Time Reason for Visit

Owner Information

First Name

Last Name

Street Address

Email Phone Place of Employment Driver’s License Date of Birth

Secondary Contact

Pet Information

Pet Name Species Breed Sex Age Color Special Markings Regular Veterinarian Pet Insurance If yes, provider How did you hear about us?

Condition Timing

Tell us when the issue began.

2 Days Ago Yesterday Today

Condition Status

Had this problem before? If yes, how long ago?

General Condition

Activity Temperature Appetite Thirst

Symptoms

Coughing Sneezing Nasal Discharge Breathing Issues

Vomiting? How often? Description

Medical History

Diet

Full Medical History

Has your pet had vomiting? If yes, how often? What does vomit look like? Any blood? Defecation (poop) If diarrhea, describe stool / blood? Urination (pee) Abnormal urine details

Medical Background

Past injury, trauma, illness? If yes, explain Chronic conditions Kitten/puppy problems Head shaking / scratching / scooting? Possible poison exposure? Possible foreign object ingestion?

Recent Medical Tests

Last bloodwork date Last x-ray date Last fecal analysis Brought fecal sample? Last urinalysis Seen elsewhere for this issue? Concerns with blood draw?

Lifestyle

Other pets in household Travel outside Michigan?

Medications & Preventatives

On medications or supplements? Recent dose changes? Immunosuppressives or chemo? Need medication refills? FIV/Leukemia test (cats)? Flea/tick preventative? Heartworm preventative? Last dewormed Vaccines up to date?

Additional Health Questions

Adverse reaction to meds/anesthesia? Weight change? Lumps or bumps? Last time pet ate Diet description Food brand Feeding frequency Recent diet changes? Food allergies? Mobility normal? Seems painful?

Behavior & History

Last heat cycle (females) Had a litter? Bite history? Sensitive areas? Adoption details